Medicine is constantly changing, with new innovations fueled by basic science discoveries.
Medicine is constantly changing, with new innovations fueled by basic science discoveries. The practice of medicine evolves and adapts to new technologies—witness how physicians’ expected call return response times have shrunk following the advent of pagers and mobile phones. Some changes are quite basic, whereas others create a paradigm shift.
When Sands, et al. came out with the AMIA position paper on electronic communication with patients in 1998, many practicing physicians probably had not heard of e-mail. Over the years, e-mail has become such a popular communication tool—especially with the adoption of e-mail-capable mobile phones, such as the BlackBerry—that when servers go down, so does business. Although some PDAs are capable of retrieving e-mail, their days are numbered due to increasing BlackBerry and smartphone sales. The BlackBerry and newer devices “push” e-mail so that users don’t have to remember to look, creating an almost Pavlovian response that is rewarded with the sense of being more connected and time efficient.
Physicians, too, have begun to use e-mail to communicate with patients. However, in light of HIPAA requirements regarding security of communication, the open nature of e-mail address headers creates several problems. E-mail was designed to travel over various routes but arrive at one destination. Ensuring e-mail security is an extreme challenge, since the odds of both physician and patient using the same e-mail software and knowing how to encrypt and decrypt messages almost reaches the odds of winning the lottery. Perhaps such skills and knowledge base exist in patients and physicians who both have used the Torrent networks and the Usenet news groups to download ‘warez,’ although both will likely deny such skill sets.
RelayHealth, a subsidiary of McKessson, has created a simple solution. It only requires that both the patient and provider have a computer with an Internet browser and connection. The service is simple to use and secure and works whether one uses a Macintosh or PC computer or Internet Explorer, Firefox or other Web browser. Patients log in under a secured SSL connection, and are provided menu options to indicate the nature of their need for communication. The site-based structured query helps identify for the responding physician the nature of the communication and whether it requires further discussion during an offi ce visit. It also indicates whether the patient wants to set up an appointment, get medication refills, etc. Physician users have reported RelayHealth has decreased their time on the telephone, and patients report satisfaction with the nature of the electronic communication. Even health plans are off ering fi nancial incentives for physicians to utilize this service, because better communication may mean better health for members, which would create less costs for the health plan. Prescriptions can also be routed through the service, which may decrease medication errors.
Although Google and Microsoft now provide PHRs, which would facilitate dissemination of information between health providers, the public may be leery of the data aggregation and privacy roles of the companies. RelayHealth’s system provides a secure messaging space for communication between health providers.
In the clinical practice of psychiatry, it is well known that there are few absolute predictors of effi cacy in terms of antidepressant, antipsychotic, and mood stabilization medication. Psychiatrists watch for distinctions such as low energy, which may make the consideration of bupropion HCL, venlafaxine, and duloxetine HCL—antidepressants with more than one neurotransmitter in the method of action—to be of more likely benefi t. Although there are no guarantees, when psychiatrists hear that a family member has benefi ted from a medication, the initial instinct is to prescribe that medication instead of taking a complete shot in the dark.
Dosage is also another issue. Many patients have stated that they are overly sensitive to medications and almost as many say that they need higher dosages for any benefi t. Th e function of the cytochrome p450 system in the liver gives credibility to these patients, because their issues are related to their genetic makeup. For example, with regards to the cytochrome p450 subsystems—such as 2D6—patients have diff erent genotypes of this system, which determines whether they are considered to be poor, intermediate, extensive, or ultra-extensive metabolizers. Drug—drug interactions and diet play a role as well in determining the efficacy of medications, but pharmacogenetics is the foundation. The Human Genome project holds great promise in that as more is understood about the genes that shape the human body, medications can be designed that are safer, more effective, and relevant for each individual.
Although the field of personalized medicine is still in its infancy, it is slowly becoming mainstream. Genelex and DNA-Worldwide are two companies that provide adverse drug reaction testing, which determines for patients what type of a metabolizer they are, with regards to the cytochrome p450 subsystem. Genetic testing plays a signifi cant role in paternity testing, but more importantly, in many diseases, such as Tay-Sachs and Fragile X. Another company, 23andMe, also offers genetic testing, but its focus is on the consumer. Although it remains to be seen how many patients will be signing up for genotyping, it represents a promising option for patients who are increasingly more proactive in fi nding information that impacts their health.
A look ahead
Medicine has always been at the forefront of scientifi c discovery, and increasingly, technology has played an important role in shaping that future. The Internet information age has seen many changes in the physician—patient relationship, including less paternalism and more collaboration, an emphasis on diagnostic testing and less history gathering, and electronic communication versus telephone calls. New technologies always raise new questions—how do we maintain privacy on the Internet? Will genetic information be used by insurers against patients attempting to get health insurance? To accurately pick the “next big thing” in medicine is always a challenge, much like picking a penny stock that will make millions, but I strongly suspect that technology will have a role.
Dr. Luo is the Physician Editor-in-Chief of MDNG: Psychiatry Edition, and chief of consultation and liaison psychiatry in the department of psychiatry at the UCLA Semel Institute for Neuroscience and Human Behavior.